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Champaign County Animal Welfare League
3858 State Route 56
Mechanicsburg, Ohio 43044
Phone 937-834-5236 Fax 937-834-5171
APPLICATION FOR CANINE ADOPTION
Date: Name of dog desired: Color(s): Age of dog desired: Oldest dog considered: Approx. weight as
an adult dog: Applicant Information Name: Address: City: State: Zip: Telephone numbers: Home: Work: Cell: E-mail Address: Date of Birth: Number of People in Household: If children are in the household, please list ages: Are you or any member of your family allergic to pets: Yes No Are you presently: Employed Employer: Unemployed Retired Student Co-Applicant Information Name: Relationship: Telephone numbers: Home: Work: Cell: E-mail Address: Date of Birth: Are you presently: Employed Employer: Unemployed Retired Student General Information Type of residence: House Apartment Condo Mobile Home Farm/Barn If rental, are dogs allowed?: Yes No Size Restrictions? Yes No Max. Size: Complex name/address: Manager/Landlord: Phone number: Current housing location: City Limits Outside City Limits Type of street: Very busy road Slight traffic Residential area Country road Speed limit: Where will dog live? Inside only Outside only Mostly inside Mostly outside Where will the dog spend nights? Inside Outside Do you have a fenced yard ? Yes No If Yes, how high? Will you allow the dog to run loose? Yes No If Yes, where? How many hours per day will the dog be alone? Where will the dog stay when left alone? Describe the activity level in your home: Busy (visits by friends, meetings, children, parties at home)
Noisy (TV, stereo, machinery, tools, children playing, dogs barking)
Moderate (Normal comings and goings)
Quiet (homebodies, few guests)
Other (specify) In the absence of the primary caregiver, who will care for the dog? Under what circumstances would you return the dog to us? New Job Divorce New Baby Move Illness Other – specify Are you willing to take responsibility if this pet acquires an illness or tests positive for heartworms? Yes No Are you willing and able to pay the veterinary costs of caring for your new pet? Yes No Are you willing to take the time to work with a dog on housebreaking or chewing, if such problems arise? Yes No Would you consider obedience training for your new dog? Yes No How much time are you prepared to allow for your new pet to adjust to your home? Pet Information Do you currently own any animals? Yes No Please list any animals owned within the past five years. Name of Pet; Type of Pet Years Owned Spayed/Neutered Inside/Outside Where is Pet Now? Yes No Inside Outside Yes No Inside Outside Yes No Inside Outside Yes No Inside Outside Yes No Inside Outside Current or past vet name of clinic: Phone: Do you consider your dog a part of the family? Yes No Will your dog be on heartworm prevention? Yes No Are you aware that a dog is a large and lifelong commitment? Yes No How did you hear about the CCAWL? Would you like to become a volunteer? Yes No Personal References # 1 Name: Relationship: Phone: Best time to contact: Comments: